Aylesbury Vale Clinical Commissioning Group Innovation & QIPP Report, September 2013

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Aylesbury Vale Clinical Commissioning Group Innovation & QIPP Report, September 2013 1.

1 Aylesbury Vale Clinical Commissioning Group Innovation & QIPP Report, September Introduction Programme Activity Finance Milestones InPACT (Urgent Care) Chronic diseases (LTCs) Early Years (Children s) Care (Right Care) Localities Joint care This report highlights the key issues and risks in the 2013/4 QIPP Plan during Month 5 (August), although much of the supporting data analysis relates to month 4. The table to the left provides a high level assessment of current and forecast delivery of the QIPP challenge in 2013/14 for each of the constituent programmes. Assessment of QIPP programme delivery is made on achievement of the required activity reduction aligned to delivery of the QIPP projects (activity and finance) and the assessment of delivery from the highlight reports (milestones). The body of the report provides a summary highlight report for each programme including the high level Key Performance Indicators (KPIs) for each programme where these have been agreed. Where they have not, work continues with programme managers to identify KPIs and these should all be in place by October (some services do not start until later in the year). More detailed highlight reports are available from the programmes.

2 2. Summary of QIPP Delivery - QIPP Finance Annual Budget Year to Date Budget Year to Date Actual Year to Date Achieved Year to Date % Impact Rating Actual Achievem ent % - INPACT 1, (60) 73% Amber 829 (260) 76% Red - Chronic Disease 1, (434) 42% Red 769 (1,068) 42% Red - Early Years (20) 0% Amber 0 (109) 0% Amber - Care 1, (126) 67% Amber 1,031 (330) 76% Red - Localities (100) 60% Amber 525 (75) 88% Amber - Joint Care % Green % Green Total Gross s 5,594 1,874 1,134 (740) 61% Red 3,752 (1,842) 67% Red Mitigtion - BHT - Use of Headroom Blue Blue Total Net QIPP Programm 5,594 1,874 1,417 (457) 76% Blue 4,430 (1,164) 79% Blue Key: High Impact/Risk of not achieving plan (variance 25%/ 250k or over Medium Impact/Risk of not achieving plan (variance against plan belo On target or marginally positive Positive variances against plan Red Amber Green Blue Risk Rating Table One (left) provides a summary of Month 5 QIPP achievement by programme and a forecast position for year end in financial terms. Actual reported position was 1,134k savings against a plan of 1,874k (61% achievement). This is partly off-set by 283k mitigation from underspend on budgets not covered by QIPP schemes The mitigated QIPP position is an under achievement of 457k (24%) The forecast position is a year-end delivery of 79% of the plan. It should be noted that it is assumed that delivery has been achieved on budgets that are currently showing as being on Plan in Prescribing and Joint Care, and for those elements that will be delivered under the risk sharing rules established within the BHT contract.

to be delivering 163K of its expected 223k (73% achievement). Summary For AVCCG, admissions at all providers are lower than last year but above plan at BHT.

3 3. QIPP Programmes 3.1 InPACT CLINICAL LEAD: DR KEVIN SUDDES RAG rating Activity Finance Milestones Table 2: Delivery of savings against plan by project InPACT Table 2 (left) shows that the InPACT programme is estimated to be delivering 163K of its expected 223k (73% achievement). Summary For AVCCG, admissions at all providers are lower than last year but above plan at BHT. However, these figures exclude admissions to CDU, SAU and the cardiac and stroke unit. CDU admissions are well above plan and leading to a significant rise in overall cost of urgent care at BHT. To identify the cause of this higher CDU activity than expected an audit has been undertaken. Results of this will inform a planned review of the CDU tariff. Pathway changes at SMH are having benefits to patents as the Trust has achieved it s A&E 4 hour standard consistently since April and there are fewer delays in ambulance handovers than at other local trusts. Key Performance Indicators (KPIs): Activity trends for emergency admissions, A&E attendances Further communications are planned to increase public awareness of alternatives to A&E for urgent care including a video for use in GP waiting rooms. Ambulance demand: Calls to SCAS have increased by 6% (569 extra calls) in AVCCG in April Aug compared to the same period last year. Analysis that SCAS has produced shows that Red 1 (life threatening) calls from 999 have remained fairly constant in Chiltern but risen in AVCCG. In addition, red (urgent and life threatening) calls from NHS 111 have added to the demand. SCAS are not allowed to re-triage these calls so this has significantly added to their workload. Patient level clinical analysis is being undertaken as part of NHS 111 work to determine whether these NHS 111 red calls, clinically required an ambulance response. This will identify whether the NHS 111 national triage pathway would benefit from modification, or whether NHS 111 is identifying new patients who warrant an ambulance but who would not have called 999.

Winter pressure funding has not been awarded to Buckinghamshire.

These include making maximum use of services such as MIIU and MuDAS, and new services such as the expanded local authority re-ablement service.

Key achievements last month: Shared Patient Notes: Completion of pilot and commenced review to decide whether system requires any modification before being rolled out across Bucks for EoL and other

4 Winter pressure funding has not been awarded to Buckinghamshire. The InPACT Board and UC JET are identifying mitigating actions to support delivery of resilient A&E services during the winter period and support change in the urgent care system. These include making maximum use of services such as MIIU and MuDAS, and new services such as the expanded local authority re-ablement service. Winter plans are being collated and submitted to the NHS England TV Area Team, to demonstrate how Buckinghamshire will manage the expected demand within existing resources. Key achievements last month: Shared Patient Notes: Completion of pilot and commenced review to decide whether system requires any modification before being rolled out across Bucks for EoL and other patients. NHS 111, Directory of Services: Review the ranking strategy for border OOHs Comms: MIIU posters have been sent out to practices. Not achieved Brokerage for self funding DTOC: Identify pilot ward and meet with hospital/ward staff. Escalated issue via InPACT Operating Board to BHT Key next steps for next month: Shared Patient Notes deployment decision depending on JET approval by end of September NHS111, finalise on report process for repeat callers for OOH s MAG s: continue presentations to 35 practices through September and October. MAGs: Roll out plan being developed in line with practices signing up to the DES. Also recruit Care Coordinator Officers x 5 working with BCC Corporate Comms: Winter messaging develop specific activities in line with funding available and create materials. Centaur: Continue to engage with GP practices in order to increase referral rates Falls & bone health: develop outline business case with an options appraisal

Children s Urgent Care: Roll out of Bronchiolitis, D&V and Head Injury including printing and disseminating of electronic copies needs to be undertaken in Sept Transforming discharge: Start of pilot

5 Children s Urgent Care: Roll out of Bronchiolitis, D&V and Head Injury including printing and disseminating of electronic copies needs to be undertaken in Sept Transforming discharge: Start of pilot of home tomorrow 3.2 Care (Right Care Steering Group) CLINICAL LEAD: DR CHRISTINE CAMPLING RAG rating Activity Finance Milestones Table 3: Delivery of savings against plan by project: Care Project Title & Brief Description (categorised by w orkstream type) Net s Net Actual From Plan Revised '000 '000 '000 '000 '000 '000 '000 New approach to follow ups 1, , Total 1, ,361 1, Key Performance Indicators: Follow-ups and elective admissions Two thirds of the QIPP savings expected from the reduction in followups are being generated (Table 3). The programme is delivering the agreed milestones. However there is a forecast over performance (at BHT) against key areas in planned care leading to the development of a mitigation plan for Care The programme has developed a draft action plan which was discussed at the RCSG 19th September. This plan will not mitigate against the total forecast overspend and there is a need to work in collaboration with other programmes for example, locality working and referral management. This Plan has been produced as a joint effort by BHT, CCGs and the CSU. The key areas that require acceleration of work are T & O complete review of pathway, management of back log, understand waiting list profile and reduce follow up appointments General Surgery - complete review of pathway including pre and post-operative management and adherence to LPP &TDP and reduce follow up appointments Dermatology escalate pace of and capacity for community clinics, widen access to teledermataology (photo links) to all GPs Ophthalmology escalate pace of discharge of glaucoma

patients to the practice, review pathway including referral of and procedures for cataracts Pathology full roll out of ICE format for ordering and education, practice information of monthly activity

Reduction in Consultant Led Follow Ups at BHT by 1.5m in year during 13/14 This project is on target against all milestones.

A business case for audio visual software programme to support non face to follow up is being discussed at the right care steering group (RCSG) on 19 th September. 3.

6 patients to the practice, review pathway including referral of and procedures for cataracts Pathology full roll out of ICE format for ordering and education, practice information of monthly activity and trends Direct Access Radiology review pathways to and between BHT and Care UK continue exploration of possible causes - check all coding and themes. Followed by revamp of protocols and education. Reduction in Consultant Led Follow Ups at BHT by 1.5m in year during 13/14 This project is on target against all milestones. Most of the reductions in follow appointments will be realised in quarters 3 and 4. So far the biggest reductions are being seen in Paediatrics and Gynaecology. A business case for audio visual software programme to support non face to follow up is being discussed at the right care steering group (RCSG) on 19 th September. 3.3 Chronic Diseases (Long Term Conditions LTCs) CLINICAL LEAD: DR STUART LOGAN RAG rating Activity Finance Milestones Table 4: Delivery of savings against plan by project: Chronic Diseases Long term conditions The Primary Care Long Term Conditions Programme covers the Psychological Therapies 'Live Well', AIM, and diabetes and respiratory skills projects. QIPP savings for these schemes are not yet being met as work to date has mostly been preparatory, or in too early stages of implementation. The Live Well clinics are receiving patients for assessment and treatment, but will take time to realise benefits to the system. Similarly, the AIM telehealth project, whilst achieving very good take up across the CCG is still completing training for practices. Key Performance Indicators: to be confirmed for LTCs and to be finalised for A risk has emerged with the Live Well project in that the required data for risk stratification cannot be captured in one practice because a mass Read code conversion is required to allow patients to be included. A solution has been identified and will be implemented. Medicines management

7 medicines management but will be in the areas of dexa scan and pathology test rates by practice. The updated national forecasting model is now available and indicates an improved forecast under spend on M3 prescribing. The interim review of the Diabetes specialist nurse post and dietician post is complete and continued funding is being sought. Anticoagulation service specification first draft complete for wider consultation. We are actively inputting into the insulin management of T2DM LES 3.4 Early Years (including Children s Urgent Care) CLINICAL LEAD: DR JULIET SUTTON RAG rating Activity Finance Milestones Table 5: Delivery of savings against plan by project: Early Years Project Title & Brief Description (categorised by w orkstream type) Net s Net Actual From Plan Revised '000 '000 '000 '000 '000 '000 '000 Paediatric urgent care Paediatric urgent care KPIs: Emergency admissions for under 5s and fever pathway (from September) plus other pathways as they come on stream. Table 5 (left) shows that the Early years programme is not delivering it s expected 17k of savings to date. Children s urgent care Following receipt of governance approval the D&V, Bronchiolitis and Head Injury pathways have been approved. D&V is now with the Quality Committee whilst Bronchiolitis and Head Injury are going through the Trust (BHT) Governance process and then will go the Quality Committee. D&V will be published on 1st October subject to Quality Committee approval and Bronchiolitis and Head injury shortly thereafter. The ChildhealthBucks website for making information regarding the local services available for children s health support and providing simple health advice is in the final stages of development and is expected to be delivered in October. A communications plan for publicising this website and health advice is being developed and will run concurrently with the publicity for the pathways, the website and the overarching social marketing campaign for urgent care in October/November. This plan will link with the central locality paediatric urgent care initiative.

8 3.5 Joint Care: CLINICAL LEAD: DR KAREN WEST RAG rating Activity Finance Milestones Table 6: Delivery of savings against plan by project: Joint Care Project Title & Brief Description (categorised by workstream type) Gross s Investment Net s Net Actual From Plan Revised '000 '000 '000 '000 '000 '000 '000 '000 '000 Reduce Grow th The following key performance indicators have now been agreed and will be monitored from the date specified. KPIs Referrals to memory clinics (from October); Number of people with a learning disability receiving a health check (from September (ie September data)); Number of practices signing up for Remote monitoring DES (from August) The QIPP savings generated through the joint care programme are related to reducing and containing growth Projects covered by programme are: Autism; Dementia; Neuro-rehab services review; Stroke support. Key achievements this month were: Autism: Review of actions from the 2012/13 action plan. Governance changes achieved so that the work sits under Integrated Care Pathways National self assessment has gone to Adult JET for discussion final comments due on 20/09/13 Self assessment has been forwarded to Autism Strategy Board for comment Meeting held with Cheryl Gillian MP, NAS and local carers to discuss developments locally. Dementia: Dementia friendly community coordinator post has gone out to advert. PTL on Dementia and Frail Elderly for AVCCG

9 MRI Scans initial discussion has taken place before meeting is arranged to agree change to the protocol for Dementia patients. Four new memory clinics are under development in addition to the current three in Aylesbury, Amersham and High Wycombe. The seven clinics will give geographical coverage for the county. Neuro-rehab services review: Completion of high level mapping for inpatient, outpatient and day case pathways (covering Inpatient, community neuro-rehab & community head injury services). Comparative data gained from site visits to Nottingham Neuro Rehab Unit & Oxford Centre for Enablement (OCE) Stroke support: Further revisions to the stroke action plan ToR reviewed and direction for the Stroke Network Group agreed with CSU and Public Health leads Revised stroke patient portfolio complete and rolled out Mental Health Pathway Redesign IAPT : Funds secured for proposed 7k increase in Couples Counselling for Depression (Relate). Contract finalised and with provider Richmond Fellowship contract finalised and with provider Expanding COPD/IAPT Pathfinder geographically - project group secured agreement from SCN for evaluation funding, to include economic analysis IAPT PbR pilot in Buckinghamshire proposed - awaiting national response Education and training group established with GP clinical leadership GP clinical lead identified for Maternal & Infant MH scoping project Specialist community review: OHFT are on target with the review of CMHTs, assertive outreach, crisis/home treatment services. Pathway design is shaping up for two locality teams - covering the two CCG areas, with sub-team structures. New hospital: On track for completion within agreed timescale. Commissioner visit has taken place. Personality Disorder (complex needs) review: OHFT have carried out early discussions with the staff at the therapeutic community. OHFT contract/pbr Performance meetings are being led by the CSU. Cluster specifications are in place. Psychiatric In-Reach and Liaison Service (PIRLS Provider/

10 commissioner meetings have happened to discuss specification. Specification is agreed within a 400k per annum limit (2 years) of which 225k per annum is new investment LD Pathway and Integration: Review workshop regarding the forensic pathway with Southern Health was held on 16/9/13 in Oxford Literature review re. LD integrated services models started Challenging Behaviour: Project Initiation Document (PID) under development. Literature review of Challenging Behaviour Strategies 3.6 Localities: CLINICAL LEADS: DR CHARLES TODD & DR MALCOLM JONES RAG rating Activity Finance Milestones Table 7: Delivery of savings against plan by project: localities First out-patient attendances are above plan year to date and referral activity is above allocation But has shown a reduction compared to 2012/13 of approximately 4% across all localities. Practices in localities are being encouraged to review specialties with high referral patterns as part of the QOF QP process in 2013/14 to support the CCG to reduce utilisation of acute care. The locality meetings in October and November will be used to undertake peer review to support practices to challenge each other as to proposals to improve referral management. Central locality in particular has engaged with the use of QP to support mitigating the CCGs activity position and has made innovative suggestions regarding how practices can buddy together to improve practice, we are negotiating with the Area Team to ensure this work by practices is recognised as part of the QP process. Key Performance Indicators: First out-patient attendances and first outpatient attendances which are GP referred; diagnostic activity exact KPI to be agreed. Leg Ulcers A preferred provider for the proposed pilot scheme has been agreed and it is intended to complete the contract by early October to start as soon as possible. This is an AVCCG-wide project support is required to encourage take-up across all our practices. In the long run this should lead to

11 improved patient outcomes and reduced use of nurse time. Strengthened Parental Care for Sick Children This project is now being supported by the Communications Lead; engagement events for mothers and children are being planned for October/November and further work is being put in place to target areas of high activity. Milton Keynes Discharge Coordinator Discharge coordinator has been in post for two months, work is on-going to strengthen communication between acute, social care and primary care to support improved patient care and quality of discharge. This includes ensuring appropriate access to information and patient records. Electronic Discharge notes are now being shared between the trust and primary care at the start of admission. The Coordinator has identified a cohort of patients who are regular users of services across the healthcare system and is working with partners to understand drivers for usage patterns and solutions to support both the patients and the services. Primary Care colleagues have welcomed the support from the discharge coordinator. Care Home Matron A launch event for the care homes matron project was held on 19 th September with South Locality practices to introduce the service. The project is now moving forward to provide support on the ground to care homes and practices.

Aylesbury Vale Clinical Commissioning Group Innovation & QIPP Report, October 2013

Aylesbury Vale Clinical Commissioning Group Innovation & QIPP Report, October 2013 1. Introduction Programme Activity Finance Milestones InPACT (Urgent Care) Chronic diseases (LTCs) Early Years (Children